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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL- <br /> Application must be made in person Zoning Permit#DCPZP- -� <br /> Shoreland Zoning Permit fee is$150 <br /> A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County <br /> Zoning Division for any development within the shoreland district. <br /> Property Owner Information Agent Information <br /> Name Eric Vieth Agent Name <br /> Address 3430 Quam Drive Agent Address <br /> City,State,Zip Stoughton, WI 53589 City,State,Zip <br /> Phone 608-347-5121 Agent Phone <br /> E-Mail . E-mail <br /> enc.vieth@strand.com <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 3430 Quam Drive T6NR1OE, Section 25 '/" SW V IA NW .245 <br /> Parcel Number(s)028/0610-253-3262-0 Zoning Distri R-s <br /> CSM 2016-01306 Lot 21 Subdivision Block/Lot 2 1 <br /> Ole Quams Park Addition 1 <br /> Project Description <br /> Residential Home Construction <br /> Please answer the following questions to the best of your ability: <br /> Is the property within 300 feet of a stream or 1000 feet from a pond or lake? IR Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? 8 Yes CI No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance`? No If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes ER No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? IS*ties El No <br /> Most applications must be accompanied by a survey showing the following: <br /> >4 Property lines with dimensions <br /> 1g All existing structures Permit Fee due at time of application <br /> Any proposed structures Please have cash or check payment available <br /> Q All impervious surfaces at time of application submittal. Checks are <br /> D4 All vegetative areas payable to Dane County Zoning. The fee for <br /> X Ordinary High Water Mark a shoreland zoning permit is $150.00 and is <br /> X Topographic data (2-foot contours) non-refundable. <br /> I, the undersigned, hereby make application for a shoreland zoning permit and certify to the accuracy of the information. I <br /> further certify I am the property owner, or a duly authorized representative, and may sign this permit application on the <br /> behalf of the owner(s)of said property. <br /> Sr 3 A 7 <br /> Applicant signature: Date: <br />